musculoskeletal
Content
Trigeminal Neuralgia Pathophysiology The trigeminal nerve is the fifth cranial nerve, nerve, a responsible for sensory data such as tactition (pressure), thermoception (temperature), and nociception (pain) originating from the face above the jawline; it is also responsible for the motor function of the muscles of mastication, the muscles mastication, involved in chewing but not facial expression
The leading explanation is that a blood vessel is likely to be compressing the trigeminal nerve near its connection with the pons. The superior cerebellar artery is pons. the most-cited mostculprit. culprit. Such a compression can injure the nerve's protective myelin sheath and cause erratic and hyperactive functioning of the nerve. nerve. This can lead to pain attacks at the slightest stimulation of any area served by the nerve as well as hinder the nerve's ability to shut off the pain signals after the stimulation ends. ends.
Symptoms
The episodes of pain occur paroxysmally. To paroxysmally. describe the pain sensation, patients describe a trigger area on the face, so sensitive that touching or even air currents can trigger an episode of pain. It affects lifestyle as it can be triggered by common activities in a patient's daily life, such as eating, talking, and toothbrushing. The attacks are said to feel like stabbing electric shocks or shooting pain that becomes intractable. Individual attacks affect one side of the face at a time, last several seconds or longer, and repeats up to hundreds of times throughout the day.
Diagnosis
No single test can diagnose trigeminal neuralgia. The condition must be distinguished from other forms of facial pain that may be due to diseases of the teeth, jaw or sinuses. Magnetic resonance imaging (MRI) or computed tomography (CT) scans of the brain can eliminate some causes of trigeminal neuralgia, such as tumors, aneurysms or multiple sclerosis.
Medical Management There is no cure for trigeminal neuralgia, but most people find relief from medication Anticonvulsants such as carbamazepine, carbamazepine, oxcarbazepine, topiramate, phenytoin, oxcarbazepine, topiramate, phenytoin, or gabapentin are generally the most effective medications.
Nursing Management
Minimize the frequency and intensity of TN attacks: Apply ice packs or any readily available source of cold to the area of pain. Cold often numbs the area and will reduce the pain. Warming packs, wrapped in a towel to protect one's skin, can also provide relief as they stimulate blood flow to the area they are placed upon. Advise to get adequate rest in normal rest cycles. Instruct on stress management and keep stress levels low. Advise on practicing healthy living principles such as diet and exercise. Avoid foods that may act as nerve stimulants, such as coffee, tea, and foods that are high in sugar. Maintain adequate hydration and electrolyte levels at all time.
ANATOMY AND PHYSIOLOGY OF THE MUSCULOSKELETAL SYSTEM
The musculoskeletal system consists of the skeletal system -- bones and joints (union of two or more bones) -- and the skeletal muscle system (voluntary or striated muscles). These two systems muscles). work together to provide basic functions that are essential to life, including:
± Protection: protects the brain and internal organs ± Support: maintains upright posture
Blood cell formation: hematopoiesis
Mineral homeostasis
± Storage: stores fat and minerals. ± Leverage: A lever is a simple machine that magnifies speed of movement or force. The levers are mainly the long bones of the body and the axes are the joints where the bones meet.
Typical Arrangement of Musculoskeletal Tissues
Skeletal muscles, attached to bone by tendons, produce movement by bending the skeleton at movable joints. The connecting tendon closest to the body or head is called the proximal attachment: this is termed the origin of the muscle. The other end, the distal attachment, is called the insertion. During contraction, the insertion. origin remains stationary and the insertion moves.
The force producing the bending is always exerted as a pull by contraction, contraction, thus making the muscle shorter: Muscles cannot actively push. Reversing the push. direction in which a joint bends is produced by contracting a different set of muscles. For example, when one group of muscles contracts, an antagonistic group stretches, exerting an opposing pull, ready to reverse the direction of movement.
The contracting unit is the muscle fiber. fiber. Muscle fibers consist of two main protein strands - actin and myosin. myosin. Where the strands overlap, the fiber appears dark. Where they do not overlap, the fiber appears light. These alternating bands of light and dark give skeletal muscle its characteristic striated appearance. The trigger which starts contraction comes from the motor nerve attached to each muscle fiber at the motor end plate. plate.
Alterations in the Musculoskeletal System
FRACTURES A break in the continuity of a bone Occur when a bone is subjected to stress greater than it cab absorb Caused by direct blows, crushing forces, sudden twisting motions, and even extreme muscle contractions When the bone is broken, the adjacent structures are also affected, resulting in tissue edema, hemorrhage into the muscle and joints, joint dislocation, ruptured tendons, severed nerves, and damaged blood vessels
CLINICAL MANIFESTATIONS PainPain- continuous and increase in severity until the bone fragments are immobilized. The muscle spasm that accompanies fracture is a type of natural splitting designed to minimize further movement of the fracture fragments Loss of Function- after a fracture, the Functionextremity cannot function, because normal function of the muscle depends on the integrity of the bones to which they are attached
Deformity- displacement., angulation, or Deformityrotation of the fragments causes a deformity that is detectable when compared with the uninjured extremity; also results from tissue swelling ShorteningShortening- because of the contraction of the muscles that are attached above and below the site of fracture CrepitusCrepitus- when the extremity is examined with the hands, a grating sensation, called crepitus can be felt. It is caused by the rubbing of the bone fragments against each other
Swelling and Discoloration - localized swelling and discoloration of the skin (ecchymosis) is a result of trauma and bleeding into the tissues. These signs may develop for several hours after the injury. DIAGNOSIS X-rays CT and MRI scans may also be used.
EMERGENCY MANAGEMENT Immobilize the body part before moving the patient Splint with pads firmly bandaged over clothing; sling With an open fracture, cover wound with a clean (sterile) dressing to prevent contamination of deeper tissues
TYPES OF FRACTURES
Greenstick fracture - the bone sustains a small, slender crack. This type of fracture is more common in children, due to the comparative flexibility of their bones. Comminuted fracture - the bone is shattered into small pieces. This type of complicated fracture tends to heal at a slower rate. Simple fracture - or 'closed' fracture. The broken bone hasn't pierced the skin. Compound fracture - or 'open' fracture. The broken bone juts through the skin, or a wound leads to the fracture site. The risk of infection is higher with this type of fracture.
Pathological fracture - bones weakened by various diseases (such as osteoporosis or cancer) tend to break with very little force. Avulsion fracture - muscles are anchored to bone with tendons, a type of connective tissue. Powerful muscle contractions can wrench the tendon free, and pull out pieces of bone. This type of fracture is more common in the knee and shoulder joints. Compression fracture - occurs when two bones are forced against each other. The bones of the spine, called vertebrae, are prone to this type of fracture. Elderly people, particularly those with osteoporosis, are at increased risk.
MEDICAL MANAGEMENT ReductionReduction- restoration of the fragments to anatomical alignment and rotation 1. Closed Reduction- accomplished by Reductionbringing the bone fragments apposition through manipulation and manual traction. The extremity is held in the desired position while the physician applies a cast, a splint, or other devices. X-rays are obtained to verify that the bone fragments are correctly aligned.
2. Open Reduction- through a surgical Reductionapproach; internal fixation devices (metallic pins, wires, screws, plates, nails, or rods) may be used to hold the bone fragments in position until solid bone healing occurs. These devices may be attached to the sides of the bone, or they may be inserted through the bony fragments or directly into the the medullary cavity of the bone
Immobilization 1. Internal Fixation- achieved through Fixationthe use of screws and plates specifically designed for stability and fixation 2. External Fixation- methods of external Fixationfixation include bandages, casts, splints, continuous traction, and external fixators
Internal Fixation
External Fixations
Traction Mechanism for exerting a steady pull on parts of the body. Traction is used to reduce fractures, maintain correct alignment of bone fragments during healing, immobilize a limb while soft tissue healing takes place, overcome muscle spasm, stretch adhesions or correct deformities
Nursing Management for Patient¶s with Traction Check traction apparatus frequently to ensure that the ropes are running straight and that weights are hanging free Skin care: turn slightly from side to side, and lift up to the trapeze to relieve pressure on the skin of the sacrum; keep skin area around pins clean and dry Toileting: use a fracture pan w/ a blanket roll; urinals; be careful not to wet site of pins
CASTS
Cast holds a broken bone in place as it heals. Casts also help to prevent or decrease muscle contractions, and are effective at providing immobilization, especially after surgery. Casts immobilize the joint above and the joint below the area that is to be kept straight and without motion. For example, a child with a forearm fracture will have a long arm cast to immobilize the wrist and elbow joints.
CAST COMPOSITION
The outside, or hard part of the cast, is made from two different kinds of casting materials. plaster - white in color. fiberglass - comes in a variety of colors, patterns, and designs. Cotton and other synthetic materials are used to line the inside of the cast to make it soft and to provide padding around bony areas, such as the wrist or elbow. Special waterproof cast liners may be used under a fiberglass cast, allowing the patient to get the cast wet.
Type of Cast Short arm cast
Location Applied below the elbow to the hand Applied from the upper arm to the hand. Applied from the upper arm to the wrist.
Uses
Forearm or wrist fractures. Also used to hold the forearm or wrist muscles and tendons in place after surgery. Upper arm, elbow, or forearm fractures. Also used to hold the arm or elbow muscles and tendons in place after surgery. Upper arm, elbow, or forearm fractures. Also used to hold the arm or elbow muscles and tendons in place after surgery.
Long arm cast
Arm cylinder cast
Type of Cast Short leg cast
Location
Uses
Lower leg fractures, severe ankle sprains/strains, or fractures. Also used to hold the leg or foot muscles and tendons in place after surgery to allow healing.
Applied to the area below the knee to the foot.
Leg cylinder cast
Applied from the upper thigh to the ankle.
Knee, or lower leg fractures, knee dislocations, or after surgery on the leg or knee area.
Unilateral hip spica cast
Applied from the chest to the foot on one leg.
Thigh fractures. Also used to hold the hip or thigh muscles and tendons in place after surgery to allow healing.
One and oneone-half hip spica cast Bilateral long leg hip spica cast
Applied from the chest to the foot on one leg to the knee of the other leg. A bar is placed between both legs to keep the hips and legs immobilized.
Thigh fracture. Also used to hold the hip or thigh muscles and tendons in place after surgery to allow healing. Pelvis, hip, or thigh fractures. Also used to hold the hip or thigh muscles and tendons in place after surgery to allow healing.
Applied from the chest to the feet. A bar is placed between both legs to keep the hips and legs immobilized
Cast Care Keep the cast clean and dry. Check for cracks or breaks in the cast. Rough edges can be padded to protect the skin from scratches. Do not scratch the skin under the cast by inserting objects inside the cast. Can use a hairdryer placed on a cool setting to blow air under the cast and cool down the hot, itchy skin. Never blow warm or hot air into the cast. Do not put powders or lotion inside the cast. Elevate the cast above the level of the heart to decrease swelling. Take baths with the cast kept out of water Keep genitals always clean and dry to prevent skin irritation
Common Complications of Casts:
pain in the casted extremity, including the feeling of "pins and needles³ Compartment syndrome Pressure ulcers Disuse syndrome coldness in an extremity a sensation that the cast is too tight skin irritation where the cast meets the body rarely, infections.
CAST REMOVAL Cast removal is done by bivalving (bivalve) the cast, or cutting the cast in half longitudinally
AMPUTATION Amputation is a surgical procedure that involves removal of an extremity/limb (leg or arm) or a part of a limb (such as a toe, finger, foot, or hand), usually as a result of injury, disease, infection, or surgery (to remove tumors from bones and muscles). Amputation of the leg (above and belowbelowknee) is the most common type of amputation procedure performed.
The most common reason for an amputation is poor circulation. The lack of circulation is caused by narrowing of or damage to the arteries (also known as peripheral arterial disease). Other indications for amputation include a traumatic injury, such as severe burn or accident, or a cancerous tumor in a limb. Trauma is the leading indication for amputations in younger persons. Amputation may also be performed for acute or chronic infections that do not respond to antibiotics or surgical debridement (removal of dead or damaged tissue). In some cases, an amputation procedure may be performed due to neuroma (a thickening of nerve tissue that may develop in various parts of the body), frostbite, or arterial blockage
Surgical Management To determine how much tissue to remove, the physician will check for a pulse at a joint close to the site. Skin temperatures, color, and the presence of pain in the diseased limb will be compared with those in a healthy limb. After the initial incision, it may be decided that more of the limb needs to be removed. The physician will maintain as much of the functional stump length as possible. The physician will also leave as much healthy skin as possible to cover the stump area. If the amputation is due to trauma, the crushed bone will be removed and smoothed out to help with the use of an artificial limb. If necessary, temporary drains that will drain blood and other fluids may be inserted.
After completely removing the dead tissue, the physician may decide to close the flaps (closed amputation) or to leave the site open (open flap amputation). In a closed amputation, the wound will be sutured shut immediately. This is usually done if there is minimal risk of infection. In an open flap amputation, the skin will remain drawn back from the amputation site for several days so any infected tissue can be cleaned off. At a later time, once the stump tissue is clean and free of infection, the skin flaps will be sutured together to close the wound. A sterile bandage/dressing will be applied. The physician may place a stocking over the amputation site to hold drainage tubes and wound dressings, or the limb may be placed in traction or a splint, depending upon your particular situation.
Nursing Management Relieving pain Minimizing altered sensory perceptions Promoting wound healing Enhancing body image Helping patient to resolve grieving Promoting independent self-care selfHelping the patient to achieve physical mobility
Pain medications and antibiotics are given as needed. The amputation site dressing will be changed and monitored very closely. Physical therapy will usually begin soon after surgery. Rehabilitation will be designed to meet the needs of the individual patient. This may include gentle stretching, special exercises, and assistance in getting in and out of bed or a wheelchair. If a leg amputation was performed, patients will learn how to bear weight on their remaining limb during PT.
Family Teaching Encourage the patient and family to be active participants in care Skin care and residual limb care in the management of prosthesis Instruction and practice sessions on how to transfer and use mobility aids and other assistive devices
Stump Care/Bandaging
Contusions
A soft tissue injury produced by blunt force, such as a blow, kick, or fall. Many small blood vessels rupture and bleed into soft tissues (ecchymosis or bruising) A hematoma develops when the bleeding is insufficient to cause an appreciable collection of blood Local symptoms are (pain, swelling, discoloration) are controlled w/ intermittent application of cold.
Contusion
Strain
³muscle pull´ caused by overuse, overstretching, or excessive stress Strains are microscopic, incomplete muscle tears with some bleeding into the tissue The patient experiences soreness or sudden pain, with local tenderness on muscle use and isometric contraction
Sprain
An injury to ligaments surrounding a joint that is caused by a wrenching or twisting motion A ligament, that functions to maintain stability while permitting mobility, loses its stabilizing ability. Blood vessels rupture and edema occurs; the joint is tender, and movement of the joint becomes painful An X-ray should be done to rule out bone Xinjury (avulsion fracture may be associated with sprain)
Management of Contusion, Sprain and Strain Rest- prevents injury and promotes healing Ice- moist dry cold applied intermittently cefor 20-30 mins during the first 24-48 hrs 2024produces vasoconstriction
Compression- elastic compression ompressionbandage controls bleeding, reduces edema, and provides support for the injured tissues
Elevation- controls swelling levation-
Rheumatoid Arthritis
Pathophysiology The autoimmune reaction primarily occurs in the synovial tissue. Phagocytosis produces enzymes within the joint. The emzymes break down collagen, causing edema, proliferation of the synovial membrane, and ultimately pannus formation. Pannus destroys cartilage and erodes the bone consequently causing loss of articular surfaces and joint motion. Muscle fiber undergo degenerative changes. Tendon and ligament elasticity and contractile power are lost.
Clinical Manifestations Pain is the symptom of rheumatic disease that most commonly causes a person to seek medical attention. Other common symptoms include joint swelling, limited movement, stiffness, weakness and fatigue. Diagnosis ArthrocentesisArthrocentesis- needle aspiration of synovial fluid to obtain a sample and to relieve pressure of increased fluid volume
X-ray studies ArthrographyArthrography-used to detect connective tissue disorder Bone and Joint scans Tissue biopsies Blood tests- creatinine, ESR, Uric testsAcid, others
Medical Management Medications are used to manage symptoms, control inflammation
1. Salicylates- i.e, aspirin, trisalicylate Salicylates2. NSAIDs- i.e, Diclofenac (Voltaren), NSAIDsIbuprofen, Meloxicam (Mobic), Naproxen
NonNon-pharmacologic: Exercise and Activity- to maintain and Activityimprove joint mobility and over-all overfunction
Nursing Management
Relieving pain and discomfort Decreasing fatigue Promoting restorative sleep Increasing mobility Facilitating self-care selfImproving body image and coping
Nursing Diagnoses
Acute and chronic pain r/t inflammation Impaired physical mobility r/t decreased ROM, muscle weakness, pain on movement SelfSelf-care deficits r/t contractures, fatigue
Gout
Pathophysiology Attacks of gout appear to be r/t sudden increases or decreases of serum uric acid levels. When the urate crystals precipitate within the joint, an inflammatory response occurs and an attack of gout begins. With repeated attacks, accumulation of sodium urate crystals, called tophi, are deposited in peripheral areas of the body, such as the great toe, hands, and the ear
Gouty Arthritis
Clinical Manifestations
Acute gouty arthritis (recurrent attacks of severe articular and periarticular inflammation) Tophi Renal impairment Uric acid urinary calculi
Medical Management
Definitive diagnosis: Polarized light microscopy of the synovial fluid of the involved joint Medications:
± Colchicine- for acute pain attacks Colchicine± Probenacid-prevents tophi formation Probenacid± Allopurinol- interrupts the breakdown of Allopurinolpurines before uric acid is formed
Nursing Management Encourage patients to restrict consumption of foods high in purines, especially organ meats, and to limit alcohol intake Maintenance of normal body weight
Systemic Lupus Erythematosus Pathophysiology SLE is a result of disturbed immune regulation that causes an exaggerated production of autoantibodies. This disturbance is brought about by some combination of genetic, hormonal, and environmental factors (sunlight, thermal burns) The increase in autoantibody is thought to result from abnormal suppressor T-cell Tfunction leading to immune complex deposition and tissue damage
Clinical Manifestations Systemic manifestations:
± Involvement of the musculoskeletal system: joint swelling, tenderness and pain on movement ± Skin manifestations:papulosquamous lesions, a chronic rash that has erythematous papules or plaques and scaling and can cause scarring and pigmentation changes butterfly rash
Diagnosis Based on complete history, PE, and blood tests Skin is inspected for erythematous rashes; inspect skin for plaques on scalp, face or neck Joint swelling, tenderness, and edema may be detected in PE No single blood test confirms SLE; rather blood testing reveals moderate to severe anemia, thrombocytopenia, leukocytosis
Medical Management Medication therapy: NSAIDs, Corticosteroids (used topically for cutaneous manifestations Nursing Management Teach about disease information teach to avoid sun exposure Emphasize need for routine screenings Teach importance of continuing prescribed medication
Common Problem of the Upper Extremity Bursitis Inflammatory conditions that commonly occur in the shoulder. Bursae are fluid sacs that prevent friction between joint structures during activity. When inflamed, they are painful. The inflammation causes proliferation of synovial membrane and pannus formation Conservative treatment include: rest, intermittent ice and heat, NSAIDs
Musculoskeletal Infection
bull¶s eye rash
LYME DISEASE Caused by the sopirochete Borrelia burgdorferi, burgdorferi, transmitted to humans by ticks Ticks may feed on infected white-tailed whitedeer or white-footed mice and serve as whitevector to transmit disease Manifested by a wide range of symptoms: in its early form, a rash is often present accompanied by regional lyphadenopathy
Diagnosis The rash associated with Lyme disease is often described by having an expanding bull¶s eye appearance The diagnosis may be made when a patient has this typical rash and at least one late manifestation (e.g. arthritis, facial palsy, meningitis, carditis) Medical Management Doxycycline, Ceftriaxone, Azithromycin are commonly used abtibiotics Treatment regimen are usually 3-4 weeks 3-
Structural Disorders OSTEOPOROSIS Pathophysiology Loss of bone mass; calcitonin, which inhibits bone resorption and promotes bone formation, is decreased; estrogen, which inhibits bone breakdown, decreases with aging; parathyroid hormone increases with aging, increasing bone turnover and resorption. The consequence of these changes is net loss of bone mass over time.
Diagnosis May be identified by routine x-rays xDual energy x-ray absorptoiometry x(DEXA) which provides information about bone mineral density Quantitative ultrasounds Labs: serum calcium, phopshate, hematocrit, ESR Medical Management Pharmacologic: Biphosphonates (Alendronate [Fosamax], Risedronate [Actonel], calcitonin
Fracture management- hip fractures are managementsurgically managed by joint replacement or by closed or open reduction Nursing Management Relieving pain Improving bowel movement Preventing injury Nursing Diagnoses Acute pain r/t fracture and muscle spasm Risk for injury: additional fractures r/t osteoporosis
OSTEOMALACIA Pathophysiology Deficiency of activated Vitamin D (calcitrol) which promotes calcium absorption from the GI tract and facilitates mineralization of the bone The supply of calcium and phosphate in the extracellular fluid is low Without adequate Vit.D, calcium and phopshate are not moved to calcifiaction site in bones
Osteomalacia may result from failed calcium absorption or from excessive loss of calcium from the body Renal insufficiency results in acidosis. The body uses available calcium to combat the acidosis,and PTH stimulates the release of skeletal calcium in an attempt to establish pH. Thus bony fibrosis occurs and bony cysts form
Diagnosis X-ray Labs show low calcium and phosphorus levels and moderately elevated alkaline phosphatase Medical Management If osteomalacia is caused by malabsorption, increase Vit.D intake, along w/ supplemental calcium Exposure to sunlight If dietary in origin, a diet w/ adequate protein, increased calcium and Vit.D (e.g. fortified milk and cereals, eggs, chicken livers)
Frequently, skeletal problems associated with osteomalacia resolve themselves when the underlying nutritional deficiency or pathologic process is adequately treated Some persistent orthopedic deformities may need to be treated with braces or surgery
PAGET¶S DISEASE
The leading explanation is that a blood vessel is likely to be compressing the trigeminal nerve near its connection with the pons. The superior cerebellar artery is pons. the most-cited mostculprit. culprit. Such a compression can injure the nerve's protective myelin sheath and cause erratic and hyperactive functioning of the nerve. nerve. This can lead to pain attacks at the slightest stimulation of any area served by the nerve as well as hinder the nerve's ability to shut off the pain signals after the stimulation ends. ends.
Symptoms
The episodes of pain occur paroxysmally. To paroxysmally. describe the pain sensation, patients describe a trigger area on the face, so sensitive that touching or even air currents can trigger an episode of pain. It affects lifestyle as it can be triggered by common activities in a patient's daily life, such as eating, talking, and toothbrushing. The attacks are said to feel like stabbing electric shocks or shooting pain that becomes intractable. Individual attacks affect one side of the face at a time, last several seconds or longer, and repeats up to hundreds of times throughout the day.
Diagnosis
No single test can diagnose trigeminal neuralgia. The condition must be distinguished from other forms of facial pain that may be due to diseases of the teeth, jaw or sinuses. Magnetic resonance imaging (MRI) or computed tomography (CT) scans of the brain can eliminate some causes of trigeminal neuralgia, such as tumors, aneurysms or multiple sclerosis.
Medical Management There is no cure for trigeminal neuralgia, but most people find relief from medication Anticonvulsants such as carbamazepine, carbamazepine, oxcarbazepine, topiramate, phenytoin, oxcarbazepine, topiramate, phenytoin, or gabapentin are generally the most effective medications.
Nursing Management
Minimize the frequency and intensity of TN attacks: Apply ice packs or any readily available source of cold to the area of pain. Cold often numbs the area and will reduce the pain. Warming packs, wrapped in a towel to protect one's skin, can also provide relief as they stimulate blood flow to the area they are placed upon. Advise to get adequate rest in normal rest cycles. Instruct on stress management and keep stress levels low. Advise on practicing healthy living principles such as diet and exercise. Avoid foods that may act as nerve stimulants, such as coffee, tea, and foods that are high in sugar. Maintain adequate hydration and electrolyte levels at all time.
ANATOMY AND PHYSIOLOGY OF THE MUSCULOSKELETAL SYSTEM
The musculoskeletal system consists of the skeletal system -- bones and joints (union of two or more bones) -- and the skeletal muscle system (voluntary or striated muscles). These two systems muscles). work together to provide basic functions that are essential to life, including:
± Protection: protects the brain and internal organs ± Support: maintains upright posture
Blood cell formation: hematopoiesis
Mineral homeostasis
± Storage: stores fat and minerals. ± Leverage: A lever is a simple machine that magnifies speed of movement or force. The levers are mainly the long bones of the body and the axes are the joints where the bones meet.
Typical Arrangement of Musculoskeletal Tissues
Skeletal muscles, attached to bone by tendons, produce movement by bending the skeleton at movable joints. The connecting tendon closest to the body or head is called the proximal attachment: this is termed the origin of the muscle. The other end, the distal attachment, is called the insertion. During contraction, the insertion. origin remains stationary and the insertion moves.
The force producing the bending is always exerted as a pull by contraction, contraction, thus making the muscle shorter: Muscles cannot actively push. Reversing the push. direction in which a joint bends is produced by contracting a different set of muscles. For example, when one group of muscles contracts, an antagonistic group stretches, exerting an opposing pull, ready to reverse the direction of movement.
The contracting unit is the muscle fiber. fiber. Muscle fibers consist of two main protein strands - actin and myosin. myosin. Where the strands overlap, the fiber appears dark. Where they do not overlap, the fiber appears light. These alternating bands of light and dark give skeletal muscle its characteristic striated appearance. The trigger which starts contraction comes from the motor nerve attached to each muscle fiber at the motor end plate. plate.
Alterations in the Musculoskeletal System
FRACTURES A break in the continuity of a bone Occur when a bone is subjected to stress greater than it cab absorb Caused by direct blows, crushing forces, sudden twisting motions, and even extreme muscle contractions When the bone is broken, the adjacent structures are also affected, resulting in tissue edema, hemorrhage into the muscle and joints, joint dislocation, ruptured tendons, severed nerves, and damaged blood vessels
CLINICAL MANIFESTATIONS PainPain- continuous and increase in severity until the bone fragments are immobilized. The muscle spasm that accompanies fracture is a type of natural splitting designed to minimize further movement of the fracture fragments Loss of Function- after a fracture, the Functionextremity cannot function, because normal function of the muscle depends on the integrity of the bones to which they are attached
Deformity- displacement., angulation, or Deformityrotation of the fragments causes a deformity that is detectable when compared with the uninjured extremity; also results from tissue swelling ShorteningShortening- because of the contraction of the muscles that are attached above and below the site of fracture CrepitusCrepitus- when the extremity is examined with the hands, a grating sensation, called crepitus can be felt. It is caused by the rubbing of the bone fragments against each other
Swelling and Discoloration - localized swelling and discoloration of the skin (ecchymosis) is a result of trauma and bleeding into the tissues. These signs may develop for several hours after the injury. DIAGNOSIS X-rays CT and MRI scans may also be used.
EMERGENCY MANAGEMENT Immobilize the body part before moving the patient Splint with pads firmly bandaged over clothing; sling With an open fracture, cover wound with a clean (sterile) dressing to prevent contamination of deeper tissues
TYPES OF FRACTURES
Greenstick fracture - the bone sustains a small, slender crack. This type of fracture is more common in children, due to the comparative flexibility of their bones. Comminuted fracture - the bone is shattered into small pieces. This type of complicated fracture tends to heal at a slower rate. Simple fracture - or 'closed' fracture. The broken bone hasn't pierced the skin. Compound fracture - or 'open' fracture. The broken bone juts through the skin, or a wound leads to the fracture site. The risk of infection is higher with this type of fracture.
Pathological fracture - bones weakened by various diseases (such as osteoporosis or cancer) tend to break with very little force. Avulsion fracture - muscles are anchored to bone with tendons, a type of connective tissue. Powerful muscle contractions can wrench the tendon free, and pull out pieces of bone. This type of fracture is more common in the knee and shoulder joints. Compression fracture - occurs when two bones are forced against each other. The bones of the spine, called vertebrae, are prone to this type of fracture. Elderly people, particularly those with osteoporosis, are at increased risk.
MEDICAL MANAGEMENT ReductionReduction- restoration of the fragments to anatomical alignment and rotation 1. Closed Reduction- accomplished by Reductionbringing the bone fragments apposition through manipulation and manual traction. The extremity is held in the desired position while the physician applies a cast, a splint, or other devices. X-rays are obtained to verify that the bone fragments are correctly aligned.
2. Open Reduction- through a surgical Reductionapproach; internal fixation devices (metallic pins, wires, screws, plates, nails, or rods) may be used to hold the bone fragments in position until solid bone healing occurs. These devices may be attached to the sides of the bone, or they may be inserted through the bony fragments or directly into the the medullary cavity of the bone
Immobilization 1. Internal Fixation- achieved through Fixationthe use of screws and plates specifically designed for stability and fixation 2. External Fixation- methods of external Fixationfixation include bandages, casts, splints, continuous traction, and external fixators
Internal Fixation
External Fixations
Traction Mechanism for exerting a steady pull on parts of the body. Traction is used to reduce fractures, maintain correct alignment of bone fragments during healing, immobilize a limb while soft tissue healing takes place, overcome muscle spasm, stretch adhesions or correct deformities
Nursing Management for Patient¶s with Traction Check traction apparatus frequently to ensure that the ropes are running straight and that weights are hanging free Skin care: turn slightly from side to side, and lift up to the trapeze to relieve pressure on the skin of the sacrum; keep skin area around pins clean and dry Toileting: use a fracture pan w/ a blanket roll; urinals; be careful not to wet site of pins
CASTS
Cast holds a broken bone in place as it heals. Casts also help to prevent or decrease muscle contractions, and are effective at providing immobilization, especially after surgery. Casts immobilize the joint above and the joint below the area that is to be kept straight and without motion. For example, a child with a forearm fracture will have a long arm cast to immobilize the wrist and elbow joints.
CAST COMPOSITION
The outside, or hard part of the cast, is made from two different kinds of casting materials. plaster - white in color. fiberglass - comes in a variety of colors, patterns, and designs. Cotton and other synthetic materials are used to line the inside of the cast to make it soft and to provide padding around bony areas, such as the wrist or elbow. Special waterproof cast liners may be used under a fiberglass cast, allowing the patient to get the cast wet.
Type of Cast Short arm cast
Location Applied below the elbow to the hand Applied from the upper arm to the hand. Applied from the upper arm to the wrist.
Uses
Forearm or wrist fractures. Also used to hold the forearm or wrist muscles and tendons in place after surgery. Upper arm, elbow, or forearm fractures. Also used to hold the arm or elbow muscles and tendons in place after surgery. Upper arm, elbow, or forearm fractures. Also used to hold the arm or elbow muscles and tendons in place after surgery.
Long arm cast
Arm cylinder cast
Type of Cast Short leg cast
Location
Uses
Lower leg fractures, severe ankle sprains/strains, or fractures. Also used to hold the leg or foot muscles and tendons in place after surgery to allow healing.
Applied to the area below the knee to the foot.
Leg cylinder cast
Applied from the upper thigh to the ankle.
Knee, or lower leg fractures, knee dislocations, or after surgery on the leg or knee area.
Unilateral hip spica cast
Applied from the chest to the foot on one leg.
Thigh fractures. Also used to hold the hip or thigh muscles and tendons in place after surgery to allow healing.
One and oneone-half hip spica cast Bilateral long leg hip spica cast
Applied from the chest to the foot on one leg to the knee of the other leg. A bar is placed between both legs to keep the hips and legs immobilized.
Thigh fracture. Also used to hold the hip or thigh muscles and tendons in place after surgery to allow healing. Pelvis, hip, or thigh fractures. Also used to hold the hip or thigh muscles and tendons in place after surgery to allow healing.
Applied from the chest to the feet. A bar is placed between both legs to keep the hips and legs immobilized
Cast Care Keep the cast clean and dry. Check for cracks or breaks in the cast. Rough edges can be padded to protect the skin from scratches. Do not scratch the skin under the cast by inserting objects inside the cast. Can use a hairdryer placed on a cool setting to blow air under the cast and cool down the hot, itchy skin. Never blow warm or hot air into the cast. Do not put powders or lotion inside the cast. Elevate the cast above the level of the heart to decrease swelling. Take baths with the cast kept out of water Keep genitals always clean and dry to prevent skin irritation
Common Complications of Casts:
pain in the casted extremity, including the feeling of "pins and needles³ Compartment syndrome Pressure ulcers Disuse syndrome coldness in an extremity a sensation that the cast is too tight skin irritation where the cast meets the body rarely, infections.
CAST REMOVAL Cast removal is done by bivalving (bivalve) the cast, or cutting the cast in half longitudinally
AMPUTATION Amputation is a surgical procedure that involves removal of an extremity/limb (leg or arm) or a part of a limb (such as a toe, finger, foot, or hand), usually as a result of injury, disease, infection, or surgery (to remove tumors from bones and muscles). Amputation of the leg (above and belowbelowknee) is the most common type of amputation procedure performed.
The most common reason for an amputation is poor circulation. The lack of circulation is caused by narrowing of or damage to the arteries (also known as peripheral arterial disease). Other indications for amputation include a traumatic injury, such as severe burn or accident, or a cancerous tumor in a limb. Trauma is the leading indication for amputations in younger persons. Amputation may also be performed for acute or chronic infections that do not respond to antibiotics or surgical debridement (removal of dead or damaged tissue). In some cases, an amputation procedure may be performed due to neuroma (a thickening of nerve tissue that may develop in various parts of the body), frostbite, or arterial blockage
Surgical Management To determine how much tissue to remove, the physician will check for a pulse at a joint close to the site. Skin temperatures, color, and the presence of pain in the diseased limb will be compared with those in a healthy limb. After the initial incision, it may be decided that more of the limb needs to be removed. The physician will maintain as much of the functional stump length as possible. The physician will also leave as much healthy skin as possible to cover the stump area. If the amputation is due to trauma, the crushed bone will be removed and smoothed out to help with the use of an artificial limb. If necessary, temporary drains that will drain blood and other fluids may be inserted.
After completely removing the dead tissue, the physician may decide to close the flaps (closed amputation) or to leave the site open (open flap amputation). In a closed amputation, the wound will be sutured shut immediately. This is usually done if there is minimal risk of infection. In an open flap amputation, the skin will remain drawn back from the amputation site for several days so any infected tissue can be cleaned off. At a later time, once the stump tissue is clean and free of infection, the skin flaps will be sutured together to close the wound. A sterile bandage/dressing will be applied. The physician may place a stocking over the amputation site to hold drainage tubes and wound dressings, or the limb may be placed in traction or a splint, depending upon your particular situation.
Nursing Management Relieving pain Minimizing altered sensory perceptions Promoting wound healing Enhancing body image Helping patient to resolve grieving Promoting independent self-care selfHelping the patient to achieve physical mobility
Pain medications and antibiotics are given as needed. The amputation site dressing will be changed and monitored very closely. Physical therapy will usually begin soon after surgery. Rehabilitation will be designed to meet the needs of the individual patient. This may include gentle stretching, special exercises, and assistance in getting in and out of bed or a wheelchair. If a leg amputation was performed, patients will learn how to bear weight on their remaining limb during PT.
Family Teaching Encourage the patient and family to be active participants in care Skin care and residual limb care in the management of prosthesis Instruction and practice sessions on how to transfer and use mobility aids and other assistive devices
Stump Care/Bandaging
Contusions
A soft tissue injury produced by blunt force, such as a blow, kick, or fall. Many small blood vessels rupture and bleed into soft tissues (ecchymosis or bruising) A hematoma develops when the bleeding is insufficient to cause an appreciable collection of blood Local symptoms are (pain, swelling, discoloration) are controlled w/ intermittent application of cold.
Contusion
Strain
³muscle pull´ caused by overuse, overstretching, or excessive stress Strains are microscopic, incomplete muscle tears with some bleeding into the tissue The patient experiences soreness or sudden pain, with local tenderness on muscle use and isometric contraction
Sprain
An injury to ligaments surrounding a joint that is caused by a wrenching or twisting motion A ligament, that functions to maintain stability while permitting mobility, loses its stabilizing ability. Blood vessels rupture and edema occurs; the joint is tender, and movement of the joint becomes painful An X-ray should be done to rule out bone Xinjury (avulsion fracture may be associated with sprain)
Management of Contusion, Sprain and Strain Rest- prevents injury and promotes healing Ice- moist dry cold applied intermittently cefor 20-30 mins during the first 24-48 hrs 2024produces vasoconstriction
Compression- elastic compression ompressionbandage controls bleeding, reduces edema, and provides support for the injured tissues
Elevation- controls swelling levation-
Rheumatoid Arthritis
Pathophysiology The autoimmune reaction primarily occurs in the synovial tissue. Phagocytosis produces enzymes within the joint. The emzymes break down collagen, causing edema, proliferation of the synovial membrane, and ultimately pannus formation. Pannus destroys cartilage and erodes the bone consequently causing loss of articular surfaces and joint motion. Muscle fiber undergo degenerative changes. Tendon and ligament elasticity and contractile power are lost.
Clinical Manifestations Pain is the symptom of rheumatic disease that most commonly causes a person to seek medical attention. Other common symptoms include joint swelling, limited movement, stiffness, weakness and fatigue. Diagnosis ArthrocentesisArthrocentesis- needle aspiration of synovial fluid to obtain a sample and to relieve pressure of increased fluid volume
X-ray studies ArthrographyArthrography-used to detect connective tissue disorder Bone and Joint scans Tissue biopsies Blood tests- creatinine, ESR, Uric testsAcid, others
Medical Management Medications are used to manage symptoms, control inflammation
1. Salicylates- i.e, aspirin, trisalicylate Salicylates2. NSAIDs- i.e, Diclofenac (Voltaren), NSAIDsIbuprofen, Meloxicam (Mobic), Naproxen
NonNon-pharmacologic: Exercise and Activity- to maintain and Activityimprove joint mobility and over-all overfunction
Nursing Management
Relieving pain and discomfort Decreasing fatigue Promoting restorative sleep Increasing mobility Facilitating self-care selfImproving body image and coping
Nursing Diagnoses
Acute and chronic pain r/t inflammation Impaired physical mobility r/t decreased ROM, muscle weakness, pain on movement SelfSelf-care deficits r/t contractures, fatigue
Gout
Pathophysiology Attacks of gout appear to be r/t sudden increases or decreases of serum uric acid levels. When the urate crystals precipitate within the joint, an inflammatory response occurs and an attack of gout begins. With repeated attacks, accumulation of sodium urate crystals, called tophi, are deposited in peripheral areas of the body, such as the great toe, hands, and the ear
Gouty Arthritis
Clinical Manifestations
Acute gouty arthritis (recurrent attacks of severe articular and periarticular inflammation) Tophi Renal impairment Uric acid urinary calculi
Medical Management
Definitive diagnosis: Polarized light microscopy of the synovial fluid of the involved joint Medications:
± Colchicine- for acute pain attacks Colchicine± Probenacid-prevents tophi formation Probenacid± Allopurinol- interrupts the breakdown of Allopurinolpurines before uric acid is formed
Nursing Management Encourage patients to restrict consumption of foods high in purines, especially organ meats, and to limit alcohol intake Maintenance of normal body weight
Systemic Lupus Erythematosus Pathophysiology SLE is a result of disturbed immune regulation that causes an exaggerated production of autoantibodies. This disturbance is brought about by some combination of genetic, hormonal, and environmental factors (sunlight, thermal burns) The increase in autoantibody is thought to result from abnormal suppressor T-cell Tfunction leading to immune complex deposition and tissue damage
Clinical Manifestations Systemic manifestations:
± Involvement of the musculoskeletal system: joint swelling, tenderness and pain on movement ± Skin manifestations:papulosquamous lesions, a chronic rash that has erythematous papules or plaques and scaling and can cause scarring and pigmentation changes butterfly rash
Diagnosis Based on complete history, PE, and blood tests Skin is inspected for erythematous rashes; inspect skin for plaques on scalp, face or neck Joint swelling, tenderness, and edema may be detected in PE No single blood test confirms SLE; rather blood testing reveals moderate to severe anemia, thrombocytopenia, leukocytosis
Medical Management Medication therapy: NSAIDs, Corticosteroids (used topically for cutaneous manifestations Nursing Management Teach about disease information teach to avoid sun exposure Emphasize need for routine screenings Teach importance of continuing prescribed medication
Common Problem of the Upper Extremity Bursitis Inflammatory conditions that commonly occur in the shoulder. Bursae are fluid sacs that prevent friction between joint structures during activity. When inflamed, they are painful. The inflammation causes proliferation of synovial membrane and pannus formation Conservative treatment include: rest, intermittent ice and heat, NSAIDs
Musculoskeletal Infection
bull¶s eye rash
LYME DISEASE Caused by the sopirochete Borrelia burgdorferi, burgdorferi, transmitted to humans by ticks Ticks may feed on infected white-tailed whitedeer or white-footed mice and serve as whitevector to transmit disease Manifested by a wide range of symptoms: in its early form, a rash is often present accompanied by regional lyphadenopathy
Diagnosis The rash associated with Lyme disease is often described by having an expanding bull¶s eye appearance The diagnosis may be made when a patient has this typical rash and at least one late manifestation (e.g. arthritis, facial palsy, meningitis, carditis) Medical Management Doxycycline, Ceftriaxone, Azithromycin are commonly used abtibiotics Treatment regimen are usually 3-4 weeks 3-
Structural Disorders OSTEOPOROSIS Pathophysiology Loss of bone mass; calcitonin, which inhibits bone resorption and promotes bone formation, is decreased; estrogen, which inhibits bone breakdown, decreases with aging; parathyroid hormone increases with aging, increasing bone turnover and resorption. The consequence of these changes is net loss of bone mass over time.
Diagnosis May be identified by routine x-rays xDual energy x-ray absorptoiometry x(DEXA) which provides information about bone mineral density Quantitative ultrasounds Labs: serum calcium, phopshate, hematocrit, ESR Medical Management Pharmacologic: Biphosphonates (Alendronate [Fosamax], Risedronate [Actonel], calcitonin
Fracture management- hip fractures are managementsurgically managed by joint replacement or by closed or open reduction Nursing Management Relieving pain Improving bowel movement Preventing injury Nursing Diagnoses Acute pain r/t fracture and muscle spasm Risk for injury: additional fractures r/t osteoporosis
OSTEOMALACIA Pathophysiology Deficiency of activated Vitamin D (calcitrol) which promotes calcium absorption from the GI tract and facilitates mineralization of the bone The supply of calcium and phosphate in the extracellular fluid is low Without adequate Vit.D, calcium and phopshate are not moved to calcifiaction site in bones
Osteomalacia may result from failed calcium absorption or from excessive loss of calcium from the body Renal insufficiency results in acidosis. The body uses available calcium to combat the acidosis,and PTH stimulates the release of skeletal calcium in an attempt to establish pH. Thus bony fibrosis occurs and bony cysts form
Diagnosis X-ray Labs show low calcium and phosphorus levels and moderately elevated alkaline phosphatase Medical Management If osteomalacia is caused by malabsorption, increase Vit.D intake, along w/ supplemental calcium Exposure to sunlight If dietary in origin, a diet w/ adequate protein, increased calcium and Vit.D (e.g. fortified milk and cereals, eggs, chicken livers)
Frequently, skeletal problems associated with osteomalacia resolve themselves when the underlying nutritional deficiency or pathologic process is adequately treated Some persistent orthopedic deformities may need to be treated with braces or surgery
PAGET¶S DISEASE
